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Zorluk: OrtaBasic Care and Comfort

An older adult client is admitted to the surgical recovery unit immediately following a left eye cataract extraction with intraocular lens implantation. The client reports a mild 'scratchy' sensation in the operated eye and asks the nurse for help getting comfortable. Which nursing intervention regarding positioning and comfort is most appropriate?

  1. Elevate the head of the bed to 30 degrees and assist the client to rest in a supine position or on the right side.Cevap
  2. B
    Position the client on their left side with a supportive pillow to promote comfort and sleep.
  3. C
    Maintain the head of the bed completely flat for the first four hours to prevent intraocular lens displacement.
  4. D
    Direct the unlicensed assistive personnel (UAP) to assess the left eye for excessive redness or bleeding while turning the client.

Cevap

The nurse should elevate the head of the bed to 30 degrees and position the client supine or on their right (non-operative) side.
After cataract surgery, nursing care focuses on preventing an increase in intraocular pressure (IOP) and protecting the surgical site. Elevating the head of the bed to 30 degrees (Semi-Fowler's position) promotes venous drainage from the head, which helps keep IOP low. The client should be positioned either supine or on the non-operative side (the right side, in this scenario) to prevent direct pressure on the operated left eye. The reported 'scratchy' sensation is a normal, expected finding postoperatively and does not indicate a complication that requires deviation from these standard positioning protocols.

Adım Adım Çözüm

1
Analyze the procedure and the client's symptoms.
The client had left eye cataract surgery and is experiencing a normal postoperative 'scratchy' sensation.
Understanding the surgical site and expected postoperative findings dictates the appropriate comfort and safety interventions.
2
Identify the primary postoperative goals for cataract extraction.
The main goals are to prevent an increase in intraocular pressure (IOP) and protect the surgical site from trauma or direct physical pressure.
Increased IOP or direct pressure can cause hemorrhage, suture rupture, or intraocular lens displacement.
3
Evaluate the positioning options based on these physiological goals.
Elevating the head of the bed to 30 degrees promotes venous drainage (lowering IOP). Lying on the non-operative right side or back successfully avoids pressure on the left eye.
These positions are anatomically and physiologically optimal for recovery, unlike lying flat or on the operative side.
4
Assess the delegation aspect in the remaining distractors.
Delegating the assessment of the eye to a UAP is unsafe and outside their scope of practice.
Only registered nurses have the training and licensure to perform clinical assessments of surgical sites.

Anahtar Kavram

Post-Cataract Surgery Positioning and Care
Tahmini Süre:1m 0s
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Basic Care and Comfort

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